WHAT WORKS WITH PEOPLE WHO INJECT DRUGS?

It has been estimated that between 6 and 10 million people
throughout the world inject drugs. High rates of HIV infection among people who
inject drugs have been found in countries as diverse as Brazil, Thailand, India
and Myanmar (Abdul-Quader et al, 1999). In many parts of the developing
world, injecting drugs has become the most common risk behaviour associated with
HIV infection (Abdul-Quader et al, 1999) and HIV infection can spread
very rapidly this way. For example, during 1985-1987 HIV prevalence among people
who injected drugs in Bangkok was 1%. By the end of 1988, however, this figure
had increased to around 40% (Stimson, 1994).

People who inject drugs risk HIV infection in two main ways:
first, through the sharing of syringes and other injecting equipment; and
second, like other sexually active people, through unprotected sex with infected
partners. Those designing HIV-related programmes, aimed at people who inject
drugs, face a number of challenges, not least the common fixed ideas about
people who use drugs. Also, in many countries drug use is socially sanctioned,
stigmatized and illegal (Stimson, 1995). Not surprisingly, drug use generally,
and injecting drug use in particular, is often hidden. People who inject drugs
are often marginalized, which means that they may find it difficult to access
services and resources that might help them to protect their health. Some legal
restrictions may serve as barriers to HIV prevention, by prohibiting the open
provision of sterile injecting equipment for example (Abdul-Quader et al,
1999).

Evidence from Europe, North America and Australia suggests that
people who inject drugs can make considerable changes to their behaviour so as
to reduce the risk of HIV infection (Stimson, 1995). There is clear evidence
that in developed countries participation in prevention programmes also leads to
a reduction of risk behaviour among people who inject drugs. However, in
developing countries there is highly variable access to appropriate information,
education and services for people who inject drugs (Abdul-Quader et al,
1999).

IDU CASE STUDY 1

Setting:

Existing health and education service sites

Country:

India

Intervention:

Counselling and condom/bleach distribution

Sponsoring institution/organization:

SAHAI Trust (an NGO)

Outreach services for people who inject drugs were established
in 1993 in Vepery and Royapuram, India by the SAHAI Trust, a
nongovernmental organization involved in prevention and treatment of drug use. A
comprehensive assessment of HIV risk behaviour among people who inject drugs was
conducted in 1994 and identified an increase in the number of drug users
injecting opiates as well as synthetic opioids such as buprenorphine. The
research suggested that the sharing of syringes and needles as well as other
injecting equipment was very common, as were high-risk sexual practices.
Findings from this assessment provided the basis for the design of the outreach
project. A team consisting of ex-users and professional social workers provided
education, counselling and support, as well as distributing condoms and bleach,
to injecting drug users who were not reached through existing services or
through traditional health education channels.

Evaluation has involved the collection of baseline data from 125
people who inject drugs and a follow-up assessment of 161 users eighteen months
after the outreach intervention was introduced. Findings were compared with a
control group of 87 drug users from locations where there were no outreach
services. The comparison at follow-up revealed that participants from the
outreach locations had adopted significant protective and risk-reduction
behaviours. Nearly 47% of participants reported decreased sharing of needles and
syringes compared to only 35.5% from control locations. Almost 30% of users from
outreach locations always cleaned syringes, compared to only 10.3% of the
control group. There was no significant difference between the two groups in
terms of reported sexual risk behaviour.

IDU CASE STUDY 2

Setting:

Community

Country:

India

Intervention:

Outreach and drop-in services including drug substitution

Sponsoring institution/organization:

SHARAN (an NGO)

SHARAN has undertaken outreach work with people who inject drugs
in the slum areas of New Delhi, India. The project began work in
1993 as a pilot drug substitution programme and, as a result of its success, was
funded in 1995 to introduce an expanded programme using sublingual buprenorphine
tablets. A drop-in centre was established in a slum area (Nizammuddin), to serve
the drug-using population from the poorest localities in Delhi. The long-term
objective of the project was to produce absolute reductions in levels of heroin
and injecting drug use in New Delhi. It aimed to achieve this through providing
accessible health and harm reduction services to people who inject drugs whilst
simultaneously providing information on drug use and HIV/AIDS to their
communities.

The establishment of a drop-in centre providing medical care and
a substitution programme has been complemented by the provision of outreach and
community-based detoxification services. A specialized staff-training programme
has increased the capacity of the centre to address the needs of people who
inject drugs. Appropriate action, research, and the production and distribution
of IEC materials are additional project outputs.

Initial baseline surveys were carried out to inform the project
design. Some original materials for awareness campaigns were created such as
posters and street plays. Specialized training was provided to staff to develop
counselling skills, and to increase technical knowledge of drug use and
HIV/AIDS. With the establishment of the drop-in centre, drug substitution
treatment using sublingual buprenorphine, medical treatment including referrals
to other services, and specialized care for tuberculosis, STD and HIV/AIDS
management were introduced. In addition, the centre provides free needles,
syringes and condoms.

Outreach activities conducted by teams of peer educators include
educational sessions on safer drug use and safer sex, referrals to relevant
services, STD and tuberculosis treatment, and abscess management. Detoxification
camps and home-based detoxification (including the training of family and other
community members) are further components of the projects work. These
activities are supported through follow-up home visits to affected families,
providing information and counselling.

An external mid-term evaluation of the programme was carried out
in August 1996 by two senior researchers from the Indian Council of Medical
Research Unit on HIV/AIDS and Substance Abuse. In addition, at the end of the
first year, an evaluation of client responses was carried out by a private
agency. Internal evaluations are also conducted to assess both the quality of
life of clients (monthly) and the working of the programme (yearly). The
mid-term external evaluation noted two major achievements. First, the programme
has achieved a high degree of user-friendliness and, as a result,
the number of clients using the service has risen rapidly. Second, the
evaluation concluded that, as a trial of bupronorphine substitution, the
programme had been very successful in proving its safety.

During the three years of its functioning, the project reached 1
611 clients, and 356 of these used the service on a regular basis (the centre
had originally been contracted to service just 300 users). One hundred and fifty
people who injected drugs had stopped injecting altogether and 58% had
considerably reduced heroin use. There was a clear reduction in the number of
clients appearing with injecting-related abscesses, cellulitis, sinuses and
thrombophlebitis coupled with an increased HIV/AIDS awareness. During its
initial phase of operation, the project thus had a major positive impact on
reducing the extent of heroin and injecting drug use in this area of New Delhi.

IDU CASE STUDY 3

Setting:

Community drop-in centres

Country:

Ukraine

Intervention:

Information provision and condom/needle supply

Sponsoring institution/organization:

Vera, Nadezhda, Lubov (a CBO)

In response to the increasing number of people injecting drugs
in the Ukraine, a project was begun in December 1996. Two
stationary drop-in centres and one mobile outreach service were initially
created to provide free and anonymous services to people who inject drugs. Teams
of three or four volunteer workers provided services, with each team including a
volunteer who is medically trained, and a person who injects drugs. Services
have included the supply of clean needles and syringes, condom distribution,
information and counselling on HIV and production and distribution of leaflets.
Services have been extended to include young men and women who sell sex.
Although the initial impetus for the project came from the Southern Branch of
the Ukranian AIDS Centre, in May 1997 the community organization Vera, Nadezhda,
Lubov took over responsibility for the implementation of the project.

Records of attendance at centres together with daily project
records, provide important evaluation material. During the first four months of
the centres opening (up to April 1997), 4 889 visits from 1 216 people who
inject drugs were recorded. It has been estimated that contacts with the
outreach service exceeded the total number of client contacts within the two
drop-in centres. During the first six months of 1997, 114 000 syringes and 36
000 condoms were distributed. Between July and mid-October 1997, about 3 000
injecting drug users were reported to have had contact with the service.

Pre- and post-intervention studies provide additional important
evaluation data. The first survey (conducted in August 1996) involved 511 people
who injected drugs and showed a high level of risk behaviours among respondents
(58% of whom were under 25 years old). Only 43% reported using their own needles
for injection, and condom use was reported as low as 16%. In April 1997, a new
sample of 200 people who injected drugs, recruited at drop-in centres and the
outreach post, showed a much lower level of both injecting and sexual risk
behaviour.

This project has remained a community-based project and, despite
major external difficulties, has managed to maintain a continuous service. It is
run exclusively by volunteers who have other occupations as their means of
income. The close involvement of people who inject drugs in programme design and
implementation ensures a high degree of acceptability. Project activities have
had a positive impact on the reduction of risk behaviours. However, unfavourable
political and organizational conditions have been a major constraint. This,
coupled with a shortage of basic resources including syringes and educational
booklets and a dependence on volunteer involvement are limiting factors,
together with severe financial shortages.

IDU CASE STUDY 4

Setting:

Prisons and community

Country:

Mexico

Intervention:

Harm reduction and rehabilitation

Sponsoring institution/organization:

Compas A.C. (an NGO) with the support of the Pan American
Health Organization and Mexican National AIDS Programme

Since 1987, the nongovernmental organization Compas A.C. in
Northern Mexico has been developing and evaluating prevention
strategies among people who inject drugs. In 1994, with funding from the Pan
American Health Organization and with the support of Mexican National AIDS
Programme, a strategy for the introduction of harm reduction was initiated based
on Prochaskas model of stages of change. This highlights the
stages a drug user may go through before ceasing substance use. The project
promotes detoxification and rehabilitation alongside harm reduction. The overall
objective of the work is to bring about changes in behaviour ranging from giving
up the use of injected drugs, to gradual changes in behaviour, which minimize
harm to those who continue injecting. Ex-injecting drug users are involved in
outreach work. People who are at a perceived action stage (a stage
at which they have a strong intention to minimize harm or to stop using drugs)
are identified by field workers and presented with a range of intervention
options.

Fieldwork is carried out in prisons as well as in the wider
community, and people who inject drugs repeatedly come into contact with project
workers. Information leaflets are produced and distributed by the field workers.
Rehabilitation services provided by the project incorporate complementary
treatments such as acupuncture and herbal medicine. Education and support is
provided to the families and partners of people who inject drugs.

Records detailing the type and extent of services provided to
people using the project, together with follow-up surveys carried out six months
after a person enrols in the programme, provide the core of evaluation data. In
addition, baseline data have been collected at the time of enrolment. These
include demographic information and data on educational and social background
and the age at which individuals began using drugs. By mid-1997, Compas had
delivered the following harm reduction services: community outreach services to
1 380 people who inject drugs; distribution of 55 373 harm reduction packets
(including condoms, bleach and education leaflets); and 239 skills-building
sessions with social networks of people injecting drugs, as well as 2 872
individual skill-building sessions. Between 1992 and September 1997, 928 heroin
users enrolled in the rehabilitation programme.

Since the introduction in 1995 of a specific focus on young
people (under 20 years), the percentage of young people making use of the harm
minimization services has risen from 20% to 32% of the population group. Six
months after completion of rehabilitation treatment, there was a 25% decrease in
the reported use of marijuana, heroin and speedball. Amongst those who continue
using drugs, there has been change towards using drugs that are not injected.
The extensive field and outreach work of the project, together with the focus on
individual assessment and support, offers a personalized intervention approach.
Identifying injecting drug users at stages when they are positively disposed to
behavioural modification causes interventions to be better targeted.

IDU CASE STUDY 5

Setting:

Community

Country:

Belarus

Intervention:

Outreach and needle exchange

Sponsoring institution/organization:

Parents for the Future of their Children (an NGO) with the
support of WHO and UNAIDS

Established in mid-1996 and funded by WHO and UNAIDS, a project
was developed in Belarus. It was the result of an initiative from
a group of Svetlogorsk residents who were concerned about the level of injecting
drug use within their community, and the consequent risk of HIV infection from
high-risk injecting and sexual behaviours. The group evolved into an NGO called
Parents for the Future of their Children. Svetlogorsk City
authorities and the Republic AIDS Prevention Centre have also participated in
the initiative.

A needle exchange service is run at two exchange points.
Disinfectant, condoms and brochures on safe behaviour and HIV/AIDS prevention
are also made available. Information materials for the families of people who
inject drugs are produced and distributed. Volunteers provide outreach education
services to difficult to reach groups. Former injecting drug users
voluntarily clean the area around the syringe exchange points. Since October
1997, a professional lawyer has offered free legal consultations to drug users.
Anonymous diagnosis and treatment for STDs is carried out at gynaecological
centres by doctors who are specially trained and sensitive to the needs of
people who inject drugs. Thirty peer educators have also been trained and a peer
education project established.

Daily monitoring of services, together with behavioural studies
and a final project assessment carried out in April 1998, form the core of
evaluations to date. In addition, and for the first time in the country, a
method of sentinel surveillance using the blood residues in syringes was
introduced. The syringe exchange points have consistently provided services to a
minimum of 300 and a maximum of 700 people who inject drugs each month. The
final assessment, conducted by a commission of international, regional and
national experts, together with a second behavioural study, have detected a
consistent behavioural change towards less risky practices among people who
inject drugs coming into contact with the project. The primary behavioural study
showed that 92% of respondents had a high degree of risk of HIV infection. The
secondary study showed this indicator to be reduced to 43%. The number of
representatives of the target group who did not use condoms likewise decreased
from 71% (pre-intervention) to 30%.

The quality and scope of the information and educational work
were positively assessed. The fact that this project was initiated at community
level has given it a strong impetus and afforded it a high level of acceptance.
Its focus on the close involvement of people who inject drugs in a range of
project activities has rendered it highly accessible to members of the target
group. The project has had an additional impact on promoting a positive attitude
towards preventive interventions on the part of local authorities and the
population of the city. There is a plan to reproduce the positive experience of
the Svetlogorsk project in other regions of the
country.